Healthcare claims payors are susceptible to fraud, abuse and errors due to the complex rules, regulations, and calculations applied in the payment process and data integrity issues that are common in payor systems. Credible estimates of the overall amount of losses in health care payments processes range from 5% to 15% of the total reimbursements. Because the amount of reimbursement is greater than a trillion dollars per year in the United States, the losses translate to many billions of dollars per year.
Current healthcare claims payor processes for ensuring payment integrity are often manually intensive and ineffective. Typically, an auditing specialist investigates data records related to a claim, resolves the claim, and issues a payment or requests a refund from the associated party. Significant overpayments and underpayments are not identified due to low use of sophisticated analytical techniques. The payor processes currently in place are not optimized for efficiency, which inhibits the ability of claims payors to dedicate sufficient headcount to manage payment integrity given budget constraints. An array of niche vendors serve the healthcare claims payor market supporting limited services to help manage the problem but do not provide integrated and sophisticated solutions to the root causes of payment integrity problems. Consequently, the above-mentioned inefficiencies result in additional costs in administering an insurance program. Ultimately, individuals paying insurance premiums must bear the costs. Moreover, current approaches are typically focused on post-payment recovery as opposed to pre-payment prevention. Post-payment recoveries are on average only recouped 75% of the time, and are administratively costly to process when compared to pre-payment prevention.
Therefore, there exists a need in the art for systems and methods that assist healthcare claims payors in identifying and resolving payment integrity issues.